Oxygen misadventure leads to macabre death


By Tessa Hoffman

16 Aug 2017

A COPD patient suffered a “horrific” death after mainline oxygen supply was connected to his urinary catheter, causing his abdomen to blow up “like a balloon”.

It should have been a straightforward treat-and-discharge scenario when Stephen Herczeg presented for a urinary tract infection at the Queen Elizabeth Hospital in South Australia’s Woodville.

But instead the 72-year-old died a “horrific” and “traumatic” death after an unknown person connected his oxygen supply tube to his catheter, eventually causing his bladder to rupture and lungs to collapse, SA state coroner Mark Johns said in findings handed down on 10 August.

Mr Herczeg arrived at the hospital emergency department in the early hours of 19 September 2016 and was put on 4 L oxygen via nasal cannula.

Around midday he was assessed by the respiratory team, who noted he was in atrial fibrillation at 150 BPM, had a clear chest X-Ray, had oxygen saturation levels of 87% on room air.

Nurse case notes entered in the hospital’s electronic communication system show the team set an acceptable oxygen saturation rate as between 85% to 92% because Mr Herczeg was a CO2 retainer.

The notes also said Mr Herczeg had 87% oxygen saturation levels on room air and the respiratory team requested for nursing staff not to commence oxygen if possible.

But the team’s request to avoid oxygen was not followed.

At 2.55 pm nurse observations record Mr Herczeg saturating at 96% on 2 litres of oxygen via nasal cannula, the nurse later conceding he did not understand the dangers of administering too much oxygen to a CO2 retainer.

It is unclear whether Mr Herczeg was receiving oxygen during transfer to the ward, based on evidence given by nurses and case notes in the system.

But a nurse did connect his nasal cannulas to mainline oxygen supply when he arrived at ward South 1 at about 3 pm.

For the next two hours, nurse observation of Mr Herczeg was minimal, with staff attending three times at most, which the coroner described as inadequate given the COPD patient was not on continuous pulse and oximetry monitoring.

At 5:05 pm Mr Herczeg was heard yelling in pain.

A nurse found him curled in foetal position and left immediately to page a doctor to enquire if pain relief could be given.

A second nurse then went to Mr Herczeg’s and finding him unresponsive, raised the alarm.

 The coroner said Mr Herczeg’s “cruelly painful” death was “entirely preventable”.

“In the awful and macabre circumstances of Mr Herczeg’s death his body filled much like a balloon, causing internal disruption. The pressure of the gas prevented him from being able to fill his lungs and he died because he could not breathe.”

But the coroner did not make a call on who connected the oxygen supply to the indwelling catheter – which had been inserted a month earlier – a complex and multi-step mechanical task which required co-ordination and strength.

He said he could not rule out Mr Herczeg, who had been confused and known to fiddle with catheter tubing.

Equally there was no evidence to rule out a nurse or another person had not carried out the task.

“I am reluctant to reach the conclusion that Mr Herczeg did this to himself because of the complexity of the task and the multiple manoeuvres referred to above. However, I cannot exclude the possibility that he did it himself, implausible as it seems. I therefore find that the tubing was interfered with by an unknown person.”

Regardless, the tragedy would not have occurred if nursing staff had kept a closer eye on their patient, the coroner found.

“There is little point in a doctor…setting a prescribed ideal oxygen range for a CO2 retainer such as Mr Herczeg if nobody thereafter does anything to ensure that he remains within it,” he said.

“In effect, Mr Herczeg was put on a set and forget regime with respect to his oxygen supply on Ward South 1.

“It is plain to me that the nursing staff responsible for his care on Ward South 1 did not provide an adequate level of care and supervision to Mr Herczeg.

“Had they done so, this tragic event would not have occurred.”

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